Housing

Personal Declaration Form

Complete the Personal Declaration Form to report change to your income, household members, or other required information for your Housing Choice Voucher in Pittsburg, KS.

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Personal Declaration Form

Personal Declarations

Change of Status Personal Declaration Form

1Personal Information

2Change of Address

3Change of Household Members

4Change in Income

5Questionnaire

6Income and/or Benefit sources

7Expenses / Deductions

8Terms and Agreement

9Review Submission

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Unique ID

Personal Information

Name(Required)

First Last

Last 4 of SSN(Required)

Date

Program Enrolled(Required)

Housing Choice Voucher Program

Tenant Based Rental Assistance Program

Phone Number

Home

Cell

Work

Message

Changes Being Made to:(Required)

Address

Household Members

Income

Change of Address

Change of Address To:

Street Address City State ZIP Code

Date that it is effective:(Required)

Change of Household Members

List all persons living in your home now.

People currently living in your home.

First Name

Middle Initial

Last Name

List only those persons below whom you are adding to or removing from your home.

Adding or Removing People

People Added / Removed from Household

Change in Income:

Change of Income Explanation(Required)

Questionnaire

Children and Disability

1. Do you have custody of minor children living with you?(Required)

YES

Not Applicable

2. Are you working with an agency to obtain custody? (If yes, provide name of agency)(Required)

YES

Not Applicable

Agency used to obtain custody(Required)

3. Do you have a Reintegration Plan for children to return to the home?(Required)

YES

Not Applicable

4. Do you wish to declare you or your spouse disabled or handicapped? (Please identify household member(s) by name)(Required)

YES

Household members names declared as disabled(Required)

First Name

Last Name

Previous Subsidies

5. Have you been assisted in other Federal Subsidized Housing programs in the past?(Required)

YES

Agency where money is owed?(Required)

Name of Agency

When

Where

6. Have you or a member of your household been evicted from a Federal Subsidized Housing in the past five (5) years? (If yes, why)(Required)

YES

Reason for Eviction(Required)

Education History

7. Are you or a member of your household a full time student? (Please identify household member(s) by name and school)(Required)

YES

Household member(s) by name and school(Required)

Household member's name

School

Criminial History

8. Have you or any member of your household been evicted from federally assisted housing due to drug related or criminal activity in the past three (3) years? (Please identify household member(s) by name)(Required)

YES

Household members with criminal activity by name(Required)

First

Last

9. Are you or any member of your household subject to registration to meet the requirements by a state sex offender registration program? (Please identify household member(s) by name)(Required)

YES

Sex Offenders by Name(Required)

First

Last

10. Have you or any member of your household ever been convicted for production or the manufacturing of methamphetamine? (Please identify household member(s) by name)(Required)

YES

Members of household convicted for production or the manufacturing of methamphetamine(Required)

First

Last

11. Have you or any member of your household been convicted or arrested for drug related or other criminal activity in the past three (3) years? (Please identify household member(s) by name)(Required)

YES

Household members convicted or arrested for drug related or other criminal activity in the past three (3) years(Required)

First

Last

12. Are you or any member of your household currently on community corrections, probation, or parole? (identify household member(s) by name)(Required)

YES

Household members currently on community corrections, probation, or parole identified by name)(Required)

First

Last

13. Are you or any member of your household currently on community corrections, probation, or parole, check all that apply

Community Corrections

Probation

Parole

Income and/or Benefit sources

Please Select all that apply

TANF Department of Children and Families (DCF) Cash

Department of Children and Families (DCF) Food Stamps

Child Support or Alimony

Social Security (SS)

Supplemental Security Income (SSI)

Wages from Employment

Unemployment Benefits

Worker’s Compensation

Net Income from a Business

Odd Jobs

Pension/Retirement Benefits

Student Financial Aid

Regular Contribution or Gifts (money given to you)

Other

1. TANF Department of Children and Families (DCF) Cash(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

2. Department of Children and Families (DCF) Food Stamps(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

3. Child Support or Alimony(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

4. Social Security (SS)(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

5. Supplemental Security Income (SSI)(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

6. Wages from Employment(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

7. Unemployment Benefits(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

8. Worker’s Compensation(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

9. Net Income from a Business(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

10. Odd Jobs(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

11. Pension/Retirement Benefits(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

12. Student Financial Aid(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

13. Regular Contribution or Gifts (money given to you)(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

14. Other , Explain:(Required)

Assets that Exceed $5,000

Assets that exceed $5,000 – Please check all that apply

Savings Account / Checking Account

CD’s etc.

Real Estate

Savings Acct./Checking Acct.(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

CD’s, etc.

Received By Amount Mo / Wk / Hr Name of Agency/Employer

Real Estate(Required)

Received By Amount Mo / Wk / Hr Name of Agency/Employer

Deductions

Medical deductions:

Elderly

Disabled/Handicapped

If the head, spouse, or co-head of your household, is elderly or disabled/handicapped, your household may qualify for a disability/medical deduction.

Child care deduction:

Employed

Attending school (continuing education program)

Seeking employment

Expenses

Please select all expenses that apply

Child Care: Not paying out of pocket

Child Care: Paying out of pocket

Medical/Disability Expenses : Not paying out of pocket

Medical/Disability Expenses : Paying out of pocket

Doctor : Not paying out of pocket

Doctor : Paying out of pocket

Hospital: Not paying out of pocket

Hospital: Paying out of pocket

Dentist: Not paying out of pocket

Dentist: Paying out of pocket

Pharmacy: Not paying out of pocket

Pharmacy: Paying out of pocket

Health Insurance Premium: Not paying out of pocket

Health Insurance Premium: Paying out of pocket

SS Medicare Premium: Not paying out of pocket

SS Medicare Premium: Paying out of pocket at this time

Attendant Care: Not paying out of pocket at this time

Attendant Care: Paying out of pocket at this time

1. Child Care: Not paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

2. Child Care: Paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

3. Medical/Disability Expenses : Not paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

4. Medical/Disability Expenses : Paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

5. Doctor : Not paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

6. Doctor : Paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

7. Hospital: Not paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

8. Hospital: Paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

9. Dentist: Not paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

10. Dentist: Paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

11. Pharmacy: Not paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

12. Pharmacy: Paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

13. Health Insurance Premium: Not paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

14. Health Insurance Premium: Paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

15. SS Medicare Premium: Not paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

16. SS Medicare Premium: Paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

17. Attendant Care: Not paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

18. Attendant Care: Paying out of pocket at this time(Required)

Amount Mo/Wk/Hr Paid To

Consent(Required)

I agree to the certification statement.

APPLICANT/TENANT CERTIFICATION STATEMENT:
I/We certify that the information given to the Pittsburg Public Housing Authority (PHA) on
household composition, income, net family assets, allowances and deductions is accurate
and complete to the best of my/our knowledge and belief. I/We understand that false
statements or information are punishable under Federal and State law. I/We also understand
that false statements or information are grounds for termination of housing assistance.

Please review all of your submitted information for accuracy before submitting

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Community Development & Housing Department

Public Housing Authority Office – 101 N Pine St
Pittsburg, KS 66762

(620) 232-1210

Monday – Friday: 8:00 am – 5:00 pm